Service use and family-centred care in young people with severe cerebral palsy: a population-based, cross-sectional clinical survey.

PURPOSE: To assess healthcare use and family perception of family-centred care in children and young adults with severe cerebral palsy (CP) within a geographical region of the UK. METHOD: Young people (4-27years) with severe forms of CP; Gross Motor Function Classification System levels IV and V, were recruited via an established case register. Data were collected in the participant's home using a standardised background proforma and validated questionnaires. The Measure of Processes of Care was used to assess the family's perception of family-centred care. RESULTS: One-hundred and twenty-three children, young people and their families/guardians participated. Results showed high accessing of specialist services in childhood with a considerable decrease in young adults. Use of generalist services remained relatively constant. The reported use of formal respite services and support groups/youth clubs was relatively poor. Family-centred care was poor in the area of "providing general information" (2.8 ± 1.73) but more moderate in the areas of "providing specific information about the young person" (4.2 ± 1.94), "enabling and partnership" (4.2 ± 1.9), "co-ordinated and comprehensive care" (4.3 ± 1.95) and "respectful and supportive care" (4.7 ± 1.75). CONCLUSIONS: The accessing of specialist services and respite care notably decreases amongst adolescents with severe forms of CP and the perception of family-centred care amongst families was fair at best. In particular, the results highlight the need for families to be provided with more general information and advice. Implications for Rehabilitation In a quest to enhance the rehabilitation process in young people with severe forms of cerebral palsy: Commissioners and service providers need to a adopt a more rationalised, needs led approach to service provision across the lifespan of people with severe forms of cerebral palsy, to include an effective and efficient transitional period. Habilitation specialists working with young adults need to continue to recognise the importance of family-centred care in managing this complex and chronic condition. Professionals working within the healthcare system must provide better communication and improve their dissemination of information to the families of children and young people with complex needs.

Plantar pressures in children with congenital talipes equino varus--a comparison between surgical management and the Ponseti technique.

The Ponseti technique for treatment for Congenital Talipes Equinovarus (CTEV) was introduced in the authors' institution in 2001, substituting a more traditional orthopaedic approach which involved surgery. There is currently limited published information regarding the differences in clinical outcomes between these two techniques, particularly in relation to plantar pressure analysis. This study aims to determine differences in pedobarographic outcome in children with CTEV, treated with either a surgical or Ponseti approach. A high resolution pedobarograph was used to record plantar pressure distribution in 52 children with CTEV and 26 children with typical development. Data were imported into Matlab where a custom programme was developed for processing and analysing pedobarographic recordings. There were significant differences in both treatment groups compared to the typically developed group (p<0.05) for most measurements. The most salient differences between treatment groups were (i) at the hind-foot where the Ponseti group had significantly lower maximum peak pressures (p<0.05); (ii) at the lateral mid-foot where children treated by the Ponseti approach showed significantly larger peak force (p<0.001), average peak pressure (p<0.001) and maximum peak pressure (p<0.01); (iii) at the lateral fore-foot where the surgical group showed lower average peak pressure (p<0.05); and (iv) in the medial/lateral fore-foot ratio where the Ponseti group showed significantly lower values (p<0.05). Plantar pressure analysis is a complementary measurement for the assessment of gait in children with CTEV. Data presented in this study showed that while there were deviations in children with CTEV, the differences observed between treatment groups suggest children in the Ponseti group have some level of under correction or recurrence.

Pelvic kinematics and their relationship to gait type in hemiplegic cerebral palsy.

While there is general clinical consensus that children with Unilateral Spastic Cerebral Palsy (USCP) walk with an increased anterior pelvic tilt and the affected hemipelvis retracted, there is less agreement to observations in the coronal plane. Furthermore, the relationship of 3D pelvic kinematic parameters to the Winters, Gage and Hicks (WGH) hemiplegic gait classification has not been reported in the literature. Valid 3-D kinematic gait data were obtained in a representative population of 91 children with hemiplegia (56 M, mean age 10.8 yrs, age range 5-18 yrs; WGH classification Type I n=32, II n=5, III n=7, IV n=9, unclassified n=38). Deviations of symmetry and range of movement from our normative data set (n=48; 26F; mean age 9.9 yrs; age range 5-18 yrs) for mean tilt, tilt range, and difference between affected and unaffected sides for obliquity and rotation were defined as normal, mild, moderate or severe (<1 standard deviation (SD); >1<2 SD; >2<3 SD; >3 SD, respectively). Increased pelvic tilt range (>1 SD) was observed in 60.4% and pelvic retraction (>1 SD) was observed in 61.5% of USCP children in this study. Weak but significant correlations were found between WGH gait type and pelvic obliquity (ρ=0.29; p<0.01). No other correlations were found. Factors such as leg length discrepancy modify the functional leg length throughout the gait cycle contributing to the deviations observed. The evaluation of gait abnormalities in USCP should not be limited to the use of classifications based on sagittal plane kinematics but should seek to include 3D kinematics of the pelvis.

Further evidence of validity of the Gait Deviation Index.

In this paper, the relationship of the Gait Deviation Index (GDI) to gross motor function and its ability to distinguish between different Gross Motor Function Classification System (GMFCS) levels was determined. A representative sample of 184 ambulant children with CP in GMFCS levels I (n=57), II (n=91), III (n=22) and IV (n=14) were recruited as part of a population-based study. Representative gait cycles were selected following a 3D gait analysis and gross motor function was assessed using the Gross Motor Function Measure (GMFM). GDI scores were calculated in Matlab. Valid 3D kinematic data were obtained for 173 participants and both kinematic and GMFM data were obtained for 150 participants. A substantial relationship between mean GDI and GMFM-66 scores was demonstrated (r=0.70; p<0.001) with significant differences in mean GDI scores between GMFCS levels (p<0.001) indicating increasing levels of gait deviation in subjects less functionally able. The relationship between the GDI, GMFM and GMFCS in a representative sample of ambulators, lends further weight to the validity of the GDI scoring system. Furthermore it suggests that the subtleties of gait may not be wholly accounted for by gross motor function evaluation alone. Gait specific tools such as the GDI more likely capture both the functional and aesthetic components of walking.

The effects of industry standard averaging and filtering techniques in kinematic gait analysis.

INTRODUCTION: Conventional methods for determining normative gait patterns consist of filtering marker trajectories prior to processing with subsequent averaging of individual normalized data. This may result in temporal shifts of key parameters and potentially distort normative datasets. Nevertheless, this is the standard method employed by state of the art motion analysis systems. This study compared two different methods of averaging filtered and unfiltered kinematic data. METHODS: Forty-eight non-impaired children (22M, 26F, mean age 9.85 years, range 4.2-17 years) underwent three-dimensional gait analysis using a Vicon system (Vicon, Oxford, UK). Gait data were processed with and without the Woltring filtering routine, commonly used to minimize marker trajectory noise. Filtered data were imported into Matlab (MathWorks, Natick, MA) where a representative gait cycle (RGC) for each leg of all participants was selected. Mean and standard deviation values for left and right limbs (n=96) for filtered and unfiltered data were calculated for seven different parameters within the RGC, without respect to timing. Similar values were obtained using the standard method. The values from the different averaging methods with and without filtering were compared. RESULTS: Differences of up to 2.2 degrees were found between averaging methods and up to 3.31 degrees between filtered and unfiltered data. DISCUSSION: Both the Woltring filtering routine and the standard averaging method cause signal dampening. While a Matlab-based tool may afford greater scope when analysing kinematic gait data, the standard averaging method still returns representative values when utilising data from able-bodied subjects.

Arthrodiastasis in Perthes' disease. Preliminary results.

We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes' disease. We carried out a prospective trial in boys over the age of eight years and girls over seven years at the time of the onset of symptoms. The patients had minimal epiphyseal collapse and were compared with a conventionally treated, consecutive, historical control group. Arthrodiastasis was applied for approximately four months. The primary outcome measure was the extent of epiphyseal collapse at the end of the fragmentation phase. One of the 15 treated hips and nine of the 30 control hips showed a loss of height of 50% or more of the lateral epiphyseal column on the anteroposterior radiographs (Herring grade-C classification). On a Lauenstein view, one of the treated hips and 19 of the control hips showed at least a loss of height of 50% of the anterior epiphyseal column. The complications of arthrodiastasis included pin-site infection in most hips, transient joint stiffness in two, and breakage of a pin in two. The final outcome will be known when all the patients and the control group reach skeletal maturity.

The variability of goniometric measurements in ambulatory children with spastic cerebral palsy.

This study assessed the variability of six goniometric measurements commonly used in the assessment of children with cerebral palsy (CP). Three experienced paediatric physiotherapists recorded three consecutive measurements of six joint ranges from 12 children with spastic CP. A fourth measurement was recorded 1 week later. The order of measurement with regards to both joint measurement and tester, was randomised to ensure a balanced experimental design. A blinded procedure was adopted with masked goniometers and a second assessor present to record the measurement. Results, analysed using generalizability theory, showed same day and different day measurement error of +/-10-14 degrees (95% confidence limits) for the foot/thigh angle, abduction and internal rotation of the hip. The source of this was child-assessor and residual error. For ankle dorsiflexion and the popliteal angles, same day measurement error was similar. However, for joint ranges recorded on different days, error ranged from +/-18-28 degrees. The major source of this was systematic differences in measurements recorded on different days. Results show a need for caution when using goniometric measurements in clinical decision making, particularly in the more tone dependent biarticular muscles after an initial assessment.

The effect of high- and low-frequency H-wave therapy upon skin blood perfusion: evidence of frequency-specific effects.

The current study was designed to assess the putative physiological effects of H-wave therapy (HWT, a mode of therapeutic electro-stimulation) on skin blood flow in humans and to determine the relevance of frequency to any such effects. Laser Doppler flowmetry was used to record changes in blood perfusion on the dominant forearm of healthy human volunteers (n=36), who were each assigned, under randomized double blind conditions, to one of three experimental groups: placebo or HWT at 2 or 60 Hz. HWT stimulation was applied for 20 min, during which time concomitant skin temperature was recorded using three surface skin thermistors. Statistical analysis of perfusion measurement and skin temperature changes pre-, during and for up to 18 min post-HWT stimulation showed a highly significant increase in skin blood flow in the 2 Hz group when compared to placebo and 60 Hz (P

Comparative analgesic effects of H-wave therapy and transcutaneous electrical nerve stimulation on pain threshold in humans.

OBJECTIVE: To assess the comparative analgesic efficacy of H-wave therapy (HWT) and transcutaneous electrical nerve stimulation (TENS) using a mechanical model of pain threshold measurement. STUDY DESIGN: Forty-eight healthy human volunteers (24 women, 24 men) were recruited and randomly assigned into one of six experimental groups; control, HWT (placebo, 2Hz, or 60Hz), or TENS (placebo or 110Hz). For each subject, mechanical pain threshold (MPT) measurements were recorded at three standardized recording points marked on the dorsal web space of the dominant hand. Two MPT measurements were recorded at each point at the following time intervals: before treatment was initiated (baseline), after each of three consecutive 10-minute periods of stimulation (HWT or TENS), and at four intervals within 30 minutes after stimulation. In the control and placebo groups MPT measurements were recorded at similar time intervals. RESULTS: Difference scores, calculated from patients' baseline values, were analyzed by ANOVA for each of the three recording points. Although results showed a significant increase in MPT levels in all three stimulation groups when compared with their relative placebo (indicating a hypoalgesic effect), no differences were observed between the different modalities or HWT frequencies. Significant hypoalgesia continued for 5 minutes after stimulation. CONCLUSION: The findings showed that HWT and TENS provided localized hypoalgesia during stimulation and for up to 5 minutes after it. No frequency- or modality-specific effects were observed between the groups.

Failure to demonstrate any hypoalgesic effect of low intensity laser irradiation (830nm) of Erb's point upon experimental ischaemic pain in humans.

BACKGROUND AND OBJECTIVE: This study assessed the putative analgesic effect of low intensity, near-infrared laser irradiation (830nm; 1.5 & 9.0J/cm2; continuous wave). STUDY DESIGN/MATERIALS AND METHODS: The current study was completed under double-blind conditions using a standardised form of the submaximal effort tourniquet technique. Healthy naive female volunteers (n = 48) attended on two occasions for pain induction in the non-dominant upper limb, the first during which baseline data were obtained and on a second occasion during which subjects were randomly allocated to either control, placebo, or one of two treatment groups. In the treatment groups, irradiation was applied to ten points on the ipsilateral Erb's point immediately prior to the pain induction procedure at the parameters stated: For the placebo condition, sham "irradiation" was delivered by applying the laser unit without activating the probe. Pain was measured using computerised visual analogue scales and McGill Pain Questionnaires to assess "current pain intensity" and "worst pain experience," respectively. RESULTS: Whereas analysis of variance and appropriate posthoc tests showed a trend toward hypoalgesia at a radiant exposure of 1.5J/cm2, no significant effects of laser therapy were found. CONCLUSIONS: These results do not provide convincing evidence for the clinical potential of low intensity laser irradiation as a pain relieving modality, at least at the parameters used. Further work is thus necessary to provide objective quantifiable data on the putative clinical efficacy of this modality and the relevance (if any) of irradiation parameters.

The effect of H-wave therapy upon conduction in the human superficial radial nerve in vivo.

This study was designed to investigate the putative neurophysiological effects of so-called 'H-wave therapy' (HWT), a form of electrical stimulation, upon conduction latencies in the human superficial radial nerve. Antidromic compound action potentials were recorded from the superficial radial nerve in the dominant forearms of thirty-two healthy human volunteers, who were randomly assigned to a control or one. of three HWT groups (2, 16 or 60 Hz). HWT was applied under double-blind conditions for three consecutive 5 min periods. Action potentials were recorded pre-HWT and immediately after each period of stimulation, i.e. at 5, 10 and 15 min. Analysis of results showed significant increases in negative and positive peak latencies in the 16 Hz and, to a greater extent, in the 60 Hz groups when compared with controls. No changes in conduction latency were observed in the low frequency 2 Hz group. The results of this study demonstrate that HWT applied at frequencies of 16 and 60 Hz may produce a direct, localized effect upon conduction in underlying peripheral nerves.